Le infezioni nelle Unità di Terapia Intensiva: è possibile ridurne l’incidenza?

1. Le infezioni nelle Unità di Terapia Intensiva: è possibile ridurne l’incidenza? Paolo Grossi Clinica Malattie Infettive e Tropicali Università degli Studi dell’Insubria – Ospedale di Circolo e Fondazione Macchi, Varese 2nd INFECTIVOLOGY TODAY "L’infettivologia del III millennio: NON solo AIDS" PAESTUM 18-20 MAGGIO 2006

2. Studio INF-NOS 2002-04 MulticentricaPrevalenza di IN totale e per area % prevalenza Studi di prevalenza

3. Prevalenza di pazienti con IN e durata degenza al momento dello studio Tutto l’ospedale

4. Prevalenza di pazienti con IN e durata degenza al momento dello studio Area critica

5. Principali patologie infettive in pazienti ricoverati in Terapia Intensiva VENTILATOR ASSOCIATED PNEUMONIA (VAP) BLOODSTREAM INFECTION (BSI) URINARY TRACT INFECTION (UTI) INTRA ABDOMINAL INFECTION (IAI)

6. Incidence rates and distribution of pathogens most commonly isolated from monomicrobial nosocomial BSIs and associated crude mortality rates for all patients, patients in ICU, and patients in non-ICU wards. Hilmar Wisplinghoff, et al. CID 2004; 39:309–17

8. Infections in ICU • Intensive care units can be considered as ‘factories’ for creating, disseminating and amplifying resistance to antibiotics, for many reasons: • importation of resistant microorganisms at admission, • selection of resistant strains with an extensive use of broad spectrum antibiotics, • cross-transmission of resistant strains via the hands or the environment.

9. Collateral Damage from Cephalosporins & Quinolones “Collateral damage’ is a term used to refer to ecological adverse effects of antibiotic therapy; namely, the selection of drug-resistant organisms and the unwanted development of colonization or infection with multidrug-resistant organisms.” “…Neither third-generation cephalosporins nor quinolones appear suitable for sustained use in hospitals as “workhorse” antibiotic therapy….” Paterson DL. Clin Infect Dis 2004:38(Suppl 4):S341-S345

10. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004 Am J Infect Control 2004;32:470-85.

11. Perugia, 11 maggio 2006

12. Staphylococcus aureus: invasive isolates resistant to methicillin (MRSA) in 2004 (European Antimicrobial Resistance Surveillance Scheme http://www.earss.rivm.nl)

13. Enterococcus faecium: proportion of invasive isolates resistant to vancomycin in 2004. (European Antimicrobial Resistance Surveillance Scheme http://www.earss.rivm.nl)

14. Enterobatteri produttori di ESBL _____________________________________________ Pazienti Isolati ESBL No. No. (%) _____________________________________________ Ricoverati (1999)8.015 509 (6,3) Ricoverati (2003) 6.850 504 (7,4) Ambulatoriali (2003) 2.226 79 (3,5) _____________________________________________ Luzzaro F. et eal. JCM, May 2006, p. 1659–1664

15. SORVEGLIANZA NAZIONALE 2003 Pazienti ospedalizzati (n=504) Chirurgia ICU Medicina

16. VARESE VIM-1VIM-2 IMP-2 IMP-12IMP-13 MILANO VIM-1 VERONA VIM-1 VIM-2 IMP-2 CREMONA VIM-2-like TORINO VIM-1 TRIESTE VIM-1 VIM-2 PAVIA VIM-1 VIM-2 PERUGIA IMP-like SIENA VIM-1 PESCARA IMP-13 ATRI IMP-13 S. GIOVANNI ROTONDO IMP-13 GENOVA VIM-1 PISA VIM-4 L’AQUILA VIM-4 ROMA VIM-1VIM-2 IMP-2IMP-13 FOGGIA VIM-like NAPOLI VIM-1-like IMP-13 AVELLINO VIM-like IMP-13 SASSARI VIM-1-like CATANIA VIM-1 PALERMO VIM-1 VIM-11 16th ECCMID Nice, 2006 The Italian map of MBL producer has been updated on the basis of this nationwide survey. MBL-producing P. aeruginosa are present over the whole national territory, though the impact of MBL producers remains relatively low. VIM producers are more prevalent than IMP producers. Production of MBL in other GNNFs and Enterobacteriaceae is limited to occasional isolates. P. aeruginosa P. putida A. xylosoxydans Acinetobacter spp. 45th ICAAC Washington, 2005

17. Resistenza ai carbapenemici in A. baumannii in Italia

18. Model for comprehensive surveillance and prevention of health care-associated adverse events in the United States

19. Temporal Relationship between Prevalence of MRSA in One Hospital and Prevalence of MRSA in the Surrounding Community: A Time Series Analysis Screening at patient discharge should be tested as new measure to control Spread of MRSA in the community I. M. GOULD, et al. ICAAC 2004

20. Proposed schematic to classify methicillin-resistant Staphylococcus aureus (MRSA) isolates as nosocomial or community-onset strains among individuals with and individuals without health care–associated risk factors. Salgado et al. CID 2003;36:131-139

21. Evaluating the Probability of MRSA Carriage at Admission to a Large University Hospital with Endemic MRSA • Screening was performed by nasal and inguinal swabs within 24 hours of admission, and included other sites when clinically indicated. • From January through August 2003, 90% (12,072/13,440) of all admissions were screened. Overall, 399 admissions (prevalence, 3.3%) were found colonized (n=368, 92%) or infected (n=31, 8%) with MRSA. • The prevalence of positive admissions was highest in sub-acute (5.7%) and chronic care wards (12.8%). • MRSA carriers (n=355) were more likely to have one or several of the following risk factors (all p<.001): • older age • prior hospitalization • antibiotic exposure • invasive procedures • greater severity of underlying illness D. PITTET, et al. ICAAC 2004

22. The Inanimate Environment Can Facilitate Transmission Xrepresents VRE culture positive sites ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

23. The spectrum of contaminant bacterial flora of patient’s files in ICU and surgical wards. Panhotra Bodh R., et al, Am J Infect Control 2005;33:398-401

24. Splash from sink drain, toilet flushing Faucet aerator, faucet, water lines Water from vase in surgical ward Aeromonas, Acinetobacter, Pseudomonas, Flavobacterium, Flavimonas, Legionella, Mycobacteria Origin of Nosocomial Infection Microorganisms:Water Trautmann, 2005

26. Factors influencing adherence to hand-hygiene practices Observed risk factors for poor adherence to recommended hand-hygiene practices • Physician status (rather than a nurse) • Nursing assistant status (rather than a nurse) • Male sex • Working in an intensive-care unit • Working during the week (versus the weekend) • Wearing gowns/gloves • Automated sink • Activities with high risk of cross-transmission • High number of opportunities for hand hygiene per hour of patient care Adapted from Pittet D. Infect Control Hosp Epidemiol 2000;21:381–6.

27. Can we do something else ?

30. Relationship between workload (modified TIS) and the number of trained nurses on day duty per week. Dancer et al. Am J Infect Control 2006;34:10-7.

31. Relationship between workload (modified TIS) and the number of trained nurses on day duty per week. Dancer et al. Am J Infect Control 2006;34:10-7.

32. Ospedale di Varese: procedure messe in atto per il controllo delle infezioni nosocomiali 2001 Revisione dei protocolli terapeutici 2002 Adozione della richiesta motivata per l’utilizzo di alcuni antibiotici ad ampio spettro (associata ad attività di formazione) 2003 Elaborazione e diffusione di direttive interne all'ospedale per le indicazioni più importanti (gestione di CVC e dispositivi medico- chirurgici, emocolture) 2004 Revisione dei protocolli per la profilassi delle infezioni delle ferite chirurgiche 2005 Adozione di un nuovo protocollo per la disinfezione delle mani 2006 Informatizzazione della richiesta motivata di antibiotici

33. ICU Varese: percentuali di resistenza ai farmaci Staphylococcus aureus (2001-2005) 78,4 52,5

34. ICU Varese: percentuali di resistenza ai farmaci Enterococcus faecium (2001-2005) 40 25 8

35. ICU Varese: percentuali di resistenza ai farmaci Pseudomonas aeruginosa (2001-2005) 38,5 33,7 24,7 21,8

36. ICU Varese: percentuali di resistenza ai farmaci Pseudomonas aeruginosa (2001-2005) 50,2 43,1 24,1 6,7

37. ICU Varese: percentuali di resistenza ai farmaci Enterobacteriaceae (2001-2005) 24,6 20,4 14,8

38. N. di isolati 38 25 1/20 2/19 3/15 1/17 Isolati di K. pneumoniae produttore di ESBL in Terapia intensiva (2001-2005)

39. N. di isolati 5/43 1/34 1/52 1/34 2/51 Isolati di E. coli produttore di ESBL in Terapia intensiva (2001-2005) Perugia, 11 maggio 2006

40. Il controllo delle resistenze batteriche si basa su attività di: sorveglianza, controllo e formazione Sorveglianza da laboratorio Microrganismi sentinella (P. aeruginosa MDR, A. baumannii MDR, MRSA, Enterobatteri produttori di ESBL, Enterococchi VRE) Controllo delle resistenze Epidemiologia delle resistenze Profilassi antibiotica in chirurgia: protocolli e verifica applicativa Prescrizione motivata di molecole antibiotiche di classi selezionate Linee guida in patologie selezionate e nei trattamenti empirici Gestione dei CVC e dei dispositivi medico-chirurgici Protocollo lavaggio mani Misure di isolamento (VRE, C. difficile) Controllo del consumo da farmacia Formazione Migliorare la prescrizione di antibiotici con misure educative Elaborare e diffondere le direttive interne all'ospedale per le indicazioni più importanti

41. Infectious Diseases Specialists Healthcare Epidemiologists Infection Control Professionals Optimal Patient Care ClinicalPharmacists Clinical Pharmacologists Clinical Microbiologists Surgical Infection Experts Infectious Diseases Expert Resources